P.U.

(A) 113

“CONSUMER PROTECTION ACT 1999

CONSUMER PROTECTION (THE TRIBUNAL FOR CONSUMER CLAIMS)

REGULATIONS 1999

SECOND SCHEDULE

FORMS
(Regulation 4)

FORM 1
(Regulation 5)

STATEMENT OF CLAIM

IN THE TRIBUNAL FOR CONSUMER CLAIMS

AT ………………………………………………………………………………………

IN THE STATE OF ……............................................... MALAYSIA

CLAIM NO.: .......................................................

Name of Claimant : .......................................................................................................................

.......................................................................................................................

I.C. No./Passport : ......................................................................................................................

Address : ......................................................................................................................
......................................................................................................................
......................................................................................................................

Telephone No. : ......................................................................................................................

Fax No./E-mail : ......................................................................................................................

Name of Respondent/ : ......................................................................................................................

Company/Body Corporate/ .....................................................................................................................
Society/Firm ......................................................................................................................
.....................................................................................................................
I.C. No./Registration No. : ......................................................................................................................
of Company/Body ......................................................................................................................
Corporate/Society/Firm
......................................................................................................................
 P.U. (A) 113

......................................................................................................................

Address : ......................................................................................................................
......................................................................................................................
.......................................................................................................................
Telephone No. : .......................................................................................................................
Fax No./E-mail : .......................................................................................................................

Claimant’s claim is for a sum of RM: ..............................................................................................................

Particulars of Claim

Goods/Services : ......................................................................................................................

Date of Purchase/ : ......................................................................................................................

Transaction

Amount paid : .....................................................................................................................

Summary of Claim

.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................

..................................................................................... .....................................................................................
Date Signature/Thumb-print of the Claimant

..................................................................................... .....................................................................................
Date of Filing Secretary/Tribunal Officer

(SEAL)
 P.U. (A) 113

TO THE RESPONDENT:

If you dispute the Claimant's claim, you shall file your defence in Form 2
(Statement of Defence and Counter-claim) within fourteen days (14) after the service of
Form 1 (Statement of Claim).

INSTRUCTIONS TO CLAIMANT:

1. Fill in your name in full and your identity card/passport number

in the column provided.
2. Fill in the name of the Respondent in full, identity card/passport number
and his last known address in the column provided.
3. State the exact amount claimed in the column provided. The amount claimed
should not exceed RM50,000.00. If the amount exceeds RM50,000.00
then the claim shall be filed in the First Class Magistrate's Court.
4. State the particulars of your claim in the column provided. The particulars
shall state the relevant date and how the claim has arisen or what is the basis
of the claim.
5. Attach any document that can support your claim together with this Form.
6. If the column provided is insufficient, please continue on a separate sheet of paper
and write "see overleaf". Any separate sheet of paper used should be attached
to this Form.
7. Having filled in the particulars, you shall sign this Form personally.
8. Having completed this Form, you shall file this Form four (4) copies in the
Tribunal's Registry Office. You shall pay a filing fee of RM5.00. The Registry
will put the seal of the Tribunal on the four (4) copies. Two (2) copies of this Form
shall be returned to you.
9. You shall not be represented by an advocate or solicitor at the hearing.
10. You are required to serve a copy of Form 1 together with four (4) copies
of Form 2 to the Respondent, within fourteen (14) days from the date
of the Form 1 returned to you.